Darcil Berry wasn’t sleeping. She was losing weight, and she was aggressive, sometimes hurting herself. In July 2010, she was moved from a Freetown group home for people with developmental disabilities to Arbour-Fuller Hospital in Attleboro for intensive psychiatric care.

But two weeks after the 41-year-old was admitted, she was transferred to a Rhode Island hospital with head trauma and covered in bruises. She died Aug. 21, 2010, of complications from blunt-force injuries.

A state panel determined that the neglect Berry experienced qualified as abuse, after her caregivers at Arbour-Fuller could not clearly explain how she suffered such harm while assigned round-the-clock supervision. A state licensing administrator said in a letter to the hospital that the staff’s behavior “could be construed as dangerous, illegal, or inhumane.” Berry’s family filed a lawsuit in July, accusing the hospital of gross negligence.

Her case is one of three questionable deaths within 18 months in the Arbour Health System that involved staff failures identified by state or federal health regulators. The health care company, which operates Arbour-Fuller, six other inpatient psychiatric facilities, and a chain of mental health clinics in Massachusetts, has been repeatedly cited for violating patient-care standards before and since the three deaths, including citations for staffing too few nurses or relying too much on lesser-trained or temporary workers.

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Advocates for the mentally ill say Arbour’s track record raises questions about the standard of care and management of a hospital system that operates more than 1 in 5 licensed psychiatric beds in Massachusetts and serves a large number of low-income patients.

The National Alliance on Mental Illness of Massachusetts “would expect all services like this to meet the highest level of care, and this obviously is not that,” said executive director Laurie Martinelli, referring to the deaths and other substantiated complaints against Arbour.

ARAM BOGHOSIAN FOR THE BOSTON GLOBE

Arbour-HRI Hospital in Brookline is the only Arbour facility with unionized nurses and mental health workers. Employees there have filed complaints with hospital administrators about mandated overtime and staffing levels.

An Arbour spokeswoman said the company continually works to improve care and has taken steps in each case to address regulators’ concerns. A top state mental health official said the problems found at Arbour hospitals were not unusual for facilities caring for difficult patients.

The company, in a court filing, denied the Berry family’s allegations about her care. Arbour attorney Janet Bobit said in an interview Friday that Berry was severely disabled and that workers tried a variety of ways to keep her from harming herself, short of physically restraining her for 24 hours a day, and none was successful.

“The staff did an admirable job, and I think it was a very sad case,” Bobit said.

The other deaths both occurred at Arbour Hospital in Jamaica Plain. In January 2010, workers failed to alert other staffers to bring emergency equipment after they found a 47-year-old woman unresponsive in her bed, according to a federal inspection report. In the attempt to resuscitate her, no one used a defibrillator to try to restore her heartbeat.

Inspectors working for the Centers for Medicare & Medicaid Services also determined that nurses were given too much discretion in deciding when and how to administer powerful sedation drugs. They failed to monitor the woman for side effects when they injected her with an antipsychotic and other drugs as a “chemical restraint,” even after she appeared disoriented, according to the report. The hospital, in its response, said it had revised its medication policies and retrained nurses and some doctors on emergency procedures.

Arbour Hospital was cited again for its emergency response in the July 2011 death of a third patient, Derek Nally. Nursing staff allowed minutes to pass after finding the 39-year-old unresponsive and waited for supervisors to arrive before beginning resuscitation, federal inspectors found.

Since then, company spokeswoman Judy Merel said, Arbour Hospital has increased medical emergency drills from quarterly to monthly and installed an electronic charting system to improve patient monitoring.

“It’s not the kind of thing we like to see, obviously,” David Matteodo, executive director of the Massachusetts Association of Behavioral Health Systems, of which Arbour was a founding member, said of the citations. “On the other hand, I would just say, think about the whole picture.”

There is broad consensus that mental health providers are not paid enough by government or private insurers. And, as some nonprofit and academic providers cut psychiatric beds, Arbour hospitals have become “an extremely important component of the inpatient system” in Massachusetts, Matteodo said.

“The patients obviously are humans and the staff are humans, and unfortunately people make mistakes,” Matteodo said. “Things can happen in any kind of setting.”

Arbour is owned by Universal Health Services, a public company that earned more than $443 million last year and has tied its national growth to expanding in the behavioral health business.

Arbour plays a unique role in Massachusetts. With 535 licensed psychiatric beds, it serves large numbers of poor and disabled people with complex needs. State and federal programs that cover their care paid Arbour hospitals $92 million last year, more than three-quarters of their net inpatient revenue, according to state filings.

The health system operates separate specialized units to serve people with developmental disabilities and patients who are aggressive or violent.

That means the state Department of Mental Health is in the position of both regulating Arbour and relying on its hospitals to treat some of the most difficult to place patients.

Department inspectors conduct full on-site surveys every other year, visit annually for a more narrow review, and frequently respond to complaints with unannounced visits.

The agency has substantiated 46 complaints against Arbour hospitals since 2008, 11 percent of the 420 complaints verified at all psychiatric hospitals it licenses. Arbour, though, operates about 22 percent of the patient beds.

“We don’t have any concerns about Arbour as being an outlier,” said Commissioner Marcia Fowler of the state Department of Mental Health. “We do have concerns about all of our facilities. We want to be vigilant.”

Private companies have largely taken over inpatient care for the mentally ill as the state has closed hospitals and shifted more resources to helping people live at home or in a community setting.

That is an important goal, said state Representative Liz Malia, a Jamaica Plain Democrat and chairwoman of the Joint Committee on Mental Health and Substance Abuse. But, she said, she worries that the state has not found the right way to monitor all providers that have filled the role, particularly those serving the poor.

“I’m seriously concerned about the quality of care that people are going to end up with at this point,” she said.

The state’s authority is somewhat limited, especially when it comes to ensuring proper staffing. A review of the department’s inspection reports, as well as records from the Department of Public Health and the state Disabled Persons Protection Commission, show that Arbour Health System facilities have had chronic staffing problems despite intervention from regulators.

Arbour Hospital in Jamaica Plain was cited for not having enough nurses in four consecutive inspection cycles, including in 2011, the most recent survey for which records are publicly available. Two units were noted in 2009 as having per-patient nursing hours that were “well below a reasonable and safe standard.”

Repeat staffing violations were found at two other hospitals in recent years, including in 2011 at Arbour’s Quincy unit for high-intensity patients. Each time, Arbour has submitted a plan for scheduling staff and recruiting new employees.

The Disabled Persons Protection Commission substantiated at least six allegations of abuse across the Arbour system in the past three years, including one related to Berry’s death and two incidents in January at Arbour-HRI Hospital in Brookline. In one case, nurses repeatedly told a patient who requested her inhaler to wait, and the patient’s blood oxygen level dropped far below normal. Other cases involved problems with quality of care or inappropriate interactions between staff and patients.

Recruitment and retention of qualified workers is a familiar challenge in mental health care, Fowler said. Front-line employees are sometimes assaulted or verbally abused by patients who are in crisis.

“Hospitals need to make sure that people are appropriately paid so that they want to stay, that they are properly trained, and that people are supported in what are some very difficult jobs,” she said.

But her office has no role in evaluating payment or staff support systems at psychiatric hospitals.

At Arbour-HRI, the only Arbour facility with unionized nurses and mental health workers, employees repeatedly have filed complaints with hospital administrators about mandated overtime and low staffing levels at night or on units housing patients who require individual attention. They also have questioned why the hospital has no security staff despite serving patients who can be violent.

Many who work there are trying “to provide a decent standard of care in the face of a corporate philosophy that seems to relentlessly put profits ahead of patient and employee safety,” union spokesman Jeff Hall said by e-mail.

Merel, the Arbour spokeswoman, said in an e-mail that Arbour facilities have immediately responded to regulators’ concerns about staffing during past surveys and that “staff members receive ongoing training and education in crisis prevention and personal safety techniques.”

The lawsuit filed by Berry’s family in Suffolk Superior Court provides a troubling picture of how inadequate staffing may have played a role in her care.

It is clear from the records that Berry was a challenging patient, in constant motion and often hurting herself. Some Arbour-Fuller caregivers said that Berry repeatedly threw herself to the floor or banged her head on the wall, but there was no evidence that the hospital staff adequately intervened to keep Berry from injuring herself, the Disabled Persons Protection Commission determined.

One staff member assigned to work with Berry had been issued several “final” written warnings by management for falling asleep on the job, the panel’s report said. Based on the panel’s findings, the mental health department’s licensing director concluded that the hospital’s care could have endangered Berry and ordered an explanation along with corrective measures.

According to the lawsuit, a medical examiner who performed Berry’s autopsy told an investigator that some of Berry’s injuries could only have been inflicted by another person.

In a separate review, the state Department of Public Health said Berry’s case did not constitute abuse under its regulations, though it cited the facility for lesser violations. Berry’s family, which has asked for $1.3 million in damages, declined to comment for this story through attorney Kevin Considine.

After Nally’s 2011 death at Arbour Hospital, inspectors were so concerned about what they found that Medicare threatened to cut off payments to the facility.

The youngest of five siblings from Waltham, Nally had served in the Navy, worked construction as a young man, and been a playful, doting uncle. He also had struggled with substance use and bipolar
disorder.

On the morning of July 3, 2011, his sister Cathy Brennan was home preparing for the holiday when she got a call. Her younger brother was dead, a psychiatrist told her. The doctor called repeatedly in the days after, she said. He assured her that Nally had gone peacefully but offered few details.

Federal investigators reviewed a hospital videotape and concluded that nursing staff did not check on Nally every 15 minutes, as required, and delayed in beginning resuscitation when they found him unresponsive.

Because the hospital had not scheduled staff retraining on proper emergency procedures by the time they visited two weeks later, inspectors declared the hospital an “immediate jeopardy” to patients. The hospital responded with a plan of correction and regulators lifted the “jeopardy” standing.

A separate review by the Department of Mental Health determined that workers adhered to the hospital’s emergency policy but failed to conduct regular safety checks.

Nally’s family is upset that they were never notified that regulators found problems with his care — something they learned only recently from a Globe reporter. More than ever, his sisters said they want answers.

Months after his death, Nally’s girlfriend gave birth to twins.

“Two little girls have to grow up without a father,” said his sister Susan Giugno, “and we have to live our life without a brother.”

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